{"id":452758,"date":"2025-12-17T07:46:24","date_gmt":"2025-12-17T07:46:24","guid":{"rendered":"https:\/\/www.europesays.com\/us\/452758\/"},"modified":"2025-12-17T07:46:24","modified_gmt":"2025-12-17T07:46:24","slug":"how-health-insurers-weigh-whether-to-cover-certain-drugs","status":"publish","type":"post","link":"https:\/\/www.europesays.com\/us\/452758\/","title":{"rendered":"How health insurers weigh whether to cover certain drugs"},"content":{"rendered":"

Health insurance companies love to save money. But the calculations for what\u2019s cheapest don\u2019t always look the way you\u2019d expect. Insurers will sometimes choose to cover a significantly more expensive drug or device, even when there\u2019s a cheaper alternative on the shelf.<\/p>\n

The choice has less to do with the medication itself, and more to do with the costs that come downstream.<\/p>\n

When someone\u2019s throat is swelling shut from an allergic reaction, an epinephrine injector is the first thing you should grab. The injectors are made under several brand names, the most well-known is EpiPen<\/a>.\u00a0<\/p>\n

\u201cIf someone has anaphylaxis, epinephrine is the medication that will save their life,\u201d said Victoria Chadwick, a clinical pharmacist in pediatric and emergency medicine at Swedish First Hill hospital in Seattle.\u00a0<\/p>\n

Chadwick said when someone\u2019s in shock, people panic. \u201cNo matter how many times you\u2019ve been taught how to use a device, you are freaking out\u00a0because the person in front of you \u2014 or yourself \u2014 can\u2019t breathe,\u201d she said.<\/p>\n

When a kid has a life-threatening allergy, their parents keep epinephrine injectors everywhere \u2014 home, school, daycare, babysitters. But not everyone is trained to use them.<\/p>\n

That\u2019s when an injector like AUVI-Q can make a difference under pressure. It literally talks you through the process of administering the medication with a calm voice, step by step.<\/p>\n

\u201cIt might save someone\u2019s life. We can\u2019t rely on everyone always knowing the right thing to do,\u201d said Chadwick.<\/p>\n

The instructions could be life-saving, but it has a list price that is eye-watering<\/a> \u2014 AUVI-Q costs over 10 times that of the generic alternative, Adrenaclick. AUVI-Q debuted at a list price of $4,500 for two injectors.\u00a0<\/p>\n

The current version of AUVI-Q has been available for eight years but wasn\u2019t commonly on formularies (a list of drugs and devices that health insurance pays for).\u00a0But that changed this year, after insurers did the math.<\/p>\n

\u201cIt\u2019s a lot cheaper to cover even a more expensive device than it is to have someone admitted to the hospital or possibly intubated \u2014 or unfortunately pass because they don\u2019t have any device at all or the device they have wasn\u2019t used,\u201d Chadwick said.<\/p>\n

Hyunjee Kim, a health economist at the Center for Health Systems Effectiveness at Oregon Health & Sciences University, said insurance companies looked at \u201cdownstream\u201d costs when making these decisions. \u201cIt can save a lot of money downstream by reducing emergency room visits or really lengthy hospitalizations,\u201d Kim said.<\/p>\n

According to Kim, insurers look at their own member data and compare two groups: those who got access to the drug or device, and those who didn\u2019t. Then, they compare the total cost of care and mortality.<\/p>\n

If they don\u2019t have the data to analyze their own patient outcomes, insurers need good outside evidence \u2014 that could be \u201crandomized control trials or a really strong, robust retrospective study<\/a> that shows how the choice of certain drugs or medical devices can affect downstream costs,\u201d Kim said.\u00a0<\/p>\n

That\u2019s part of how AUVI-Q started getting covered. A recent independent retrospective study found 50% lower health care costs and fewer emergency visits after anaphylaxis when AUVI-Q is used during a severe allergic reaction, compared to its competitors.<\/p>\n

That was one factor in Aetna, the third largest insurance company in the U.S., making AUVI-Q its preferred epinephrine device for severe allergies.\u00a0<\/p>\n

Kaiser Permanente, the large nonprofit health insurer, did the same, partially due to internal pressure from its own clinicians. \u201cIf doctors or hospitals strongly believe in the value of certain devices or drugs, I think that can put really huge pressure on the insurer,\u201d Kim said.<\/p>\n

Plus, don\u2019t forget good old-fashioned free-market competition.\u00a0<\/p>\n

\u201cYou always have to consider what other players do,\u201d Kim said. \u201cIf my competitor does cover it, I better cover it, otherwise my member will switch.\u201d<\/p>\n

In other words, insurers don\u2019t want to lose in a shot-for-shot competition. And higher upfront costs can make sense if they prevent bigger bills later.<\/p>\n

Related Topics<\/p>\n","protected":false},"excerpt":{"rendered":"Health insurance companies love to save money. But the calculations for what\u2019s cheapest don\u2019t always look the way…\n","protected":false},"author":3,"featured_media":452759,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[34],"tags":[24320,207710,210,3168,1060,56807,67,132,68],"class_list":{"0":"post-452758","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-medication","8":"tag-allergies","9":"tag-epipen","10":"tag-health","11":"tag-health-insurance","12":"tag-medication","13":"tag-pharmaceutical-drugs","14":"tag-united-states","15":"tag-unitedstates","16":"tag-us"},"share_on_mastodon":{"url":"https:\/\/pubeurope.com\/@us\/115733802984588030","error":""},"_links":{"self":[{"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/posts\/452758","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/comments?post=452758"}],"version-history":[{"count":0,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/posts\/452758\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/media\/452759"}],"wp:attachment":[{"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/media?parent=452758"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/categories?post=452758"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/tags?post=452758"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}